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HomeMy WebLinkAbout1377A 1378A (7) � .., -, � �
) ;WORKERS'COMPENSATION,DECLARATION . . _ � �: � I. . '��
I hereby affirm�hoi I have a cerlifi[ale of consent to self _ - A P P L I CAT I O N� ��'��R� B U I L D I N G P E RMI T
insyre,or a cer�ificate of Workers'Compens�ion Insurance,or �
a tertified copy rheregf(Sec.3800,tob.C.) COUNTY OF LO$ANGELES BUILDING AND SAFETY
Policyl�Io�G�'S7 Company��1� �'��,!%+'�� .. . �.
O Cenif�ed copy is hereby furnished. � FOR APPLICANT TO FILL IN nooaess y0� ��-'� -C��
� Certified copy is filed with the county buildl g inspec- BUR�ING /' /
tian deportment. � AD�RESS 4/1/SL i , L'"L'���r� S(� !R/ S LOCnuTr ..c��..r�v � . ..
!1 JA��n NEAREST
'Date ���_ -� PPlim�� 'L�" — �iTY�6J �.�� �Rn 2 zia .. .. � . � ceosssr. �.-� � .
'CERTIfICATE OF EXEMPTION ROM WORKERS' NO.OF BLDGS. ASSESSOR " - / �
COMPENSATION INSl1RANCE � 512E OF LOT NOW ON LOT MAP 600K PAGE ARCEL
�.(This section need not be compleled if the permit is(or one TRACT S'7C Z BLOCK lOT NO. USE 7AN� OP /� _3�
. hundred dollars(5100)or less.) � -. �/ ��� ' y.
OWNER +O(�L��L�S���nl TEL. SPECIAL ' y
s y.�r�No. Pe:?�/SCG CONDIT�ON$
I tenify��hot in tha performance of the work for which this � 0
�permit is issued,I shall nol employ any person in any manner � �� • DiSiaKT GROUP TYPE FIRE PRpCE55ED BY �J
' so as to becoma subject fo the Workeri Compensation Laws. ADDRESS %'.�/J1J�/� 1` �d O CONST. 20NE /JQ,, �
.. . . . � � �� / H"a-ttlit� �
� Oate � Applicanl ' ��T v - Z�P S7ATISTICAL CLASSiFICATION APT. CONDO. V
'NOTICE TO APPLICANT: If, bfter making this Certificate Of "' ARCNRECT O��� �.,- � 1' � 7E11 f - _ . �f - . W
Exemption, you sho�ld betome s�bject to fhe-Workeri ENGINEER !2 E�� � �'YJ NO.C `1� CL455 NO. ✓ DWELL.UNITS � p,
Compensotion prpvis�ons of thw Lobor Code,you musr forth• qpp��u 7/�G /7S�cL'(/ A i1� SEWER MAP ' Z
with comply with s�th provisions or thfs permi� sholl be �+
deemedrevoked. � . CONranCtOfCt6 1=` ..�� r`'v� NO.L7�J�a^�( BK. PG, VALI�ATION ,
LICENSED CONTRACTORS DECIARATION� i�C._
I hereby affirm thal I am licensed ander provisions of Chapler 9 .. ADORESS j�J �•2 C' NO 7 G•C+�3�' . VALUATION
(commencing wiih Section 7000)of Division 3 oi the Businessond f _�
Professions Code,ond my license is in fui�force and effecl. _ CI�V ![� f(���✓�� QA55 �� 3 f (�'T'f/ .
� � -�, //� J �' SQ.F�.I NO.OF NO.OF CHECK � - .
Lifens Nu b r-� �4�rJ� Lic.Class�s SIiE S�S~I� STORIES FAMILIES ONE � ,
�j�� � . ❑ S
Conlr '�� /" " — ��'Date ��•J���� � DESCRIPTION OF WORK NEW
� a ezempt from the licensing requirements as I am a .StU Kh�y/ �`V l S�/J A�� � ' �� 3�'7 a , �
lice sed architect or a registered professionol engineer.,_.__ ,_ __ _ AIiER ❑ DAT 2 � # 2�
acting in my professional capatity (Section 7051, � � � � �'� � .
REPAIR
� Business and Professions Code). USE OF r FINA � � • •6�`Z$
E%iSTING BLDG. ,J�J I1 V � �EMOL ❑
Lic.or Reg.No. Dale /+PPtKANTt7 �f Te�. �+ e'' � 6 3 2 8 c=.i
- OWNER-BUIIDER DECIARATION '� � -(PRiNiI�SC' tI/�C 5�'�'NO.�'I�C�j^;L• �� �
I hereby oNirm that I om exempi from the CoMractori License '•�'��� '1�+�F�.�� ��L (V� y -G �.C��[/ •�JG�� . 0 1.2 9—8 2 �
. Law for the following reason(Section 7031.5,Business and ADORe55 J� / � ,/ �
Professions Code): � � � HkESEtvi �� �,,�1.G.r�-c-C-•
.O . . . BIIILDING . . . - - �
I, as owner of fhe properfy, or my empioyees wifh AD�RESS �
woges as their sole tompensolion,will da fhe work and >'JR i
� the strocture is not imended or offered ior sole(Section� ' �«A��T� - -- - . � , ' �,�'��'i'K-�V �
7044,Business and Prafessions CodeJ. , MOVING 7EL. � . � � � ��L3
'O I,a5 owner of ihe prOperty,om ez[IUSIveIy ConhOCiing-' CONTRACTOR� NO. � � �
wirh licensed contracrors ro construct the project(Sec- qoDRE55 � � �
tion 7044,Business and Professions Code). -� - � �-' ' ' /�� S�
RE�UIRED TOTAL SETBAIX FROM EXIST. '
CONSTRUCTION LENDING AGENCY � SET BACK YARD HWY PROP.LINE WIDTH � �
I heieby afkrm rhat ihere is a constrocrion lending agency for � feONl ' �' -- � - '�
the performonce of 1he work for which this permil is issued p L - � /��l'���y
(Sec.3097,Civ.C.l. . . . .. � SiDE � -- ' ' �
, P.l. .. . . . . . .
lender's Nome /, /� 1 �/ . , . " , � �
Lender's Address � � P.C.Fee S Y 3.�J perm�r Fee �✓�L��/ ' � � -
I ceriify ihat I have read this opplicotian ond eroie�hot the Issuance Fee ��� �
_ obove informotion is correcl.I ogree�o tomply wi�h all Couniy _. invesugai�on Fee .. . . . , . . . � . �.
ordinantes a Sto1e laws reloting to building conslruUion, Tmal fee /42��� ' � �
ond hereby u o�ize represen�aiives of�his Coonty to emer
' �vp e a ove-me ioned praperty(or inspecfion porpose5. . � �
i �J'�y— `. SEE REVERSE FOR EXPIANATORY LANGUAGE � � �
5 . �ura ol Appl�conr or Agem Do�e � . � �'�
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